Open Nav Close Nav

Medicare/Medi-Cal Audits, Appeals and Overpayment Disputes

Fenton Law Group works with providers who experience problems with their participation in the Medicare program, from enrollment issues to recovery audits. The incidence of Medicare recovery audits against healthcare providers is on the rise as the U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS) has identified physician “overpayments” as a promising source of financing. Through the Recovery Audit Contractor (RAC) program and other initiatives, Medicare increasingly denies providers payments or audits them for alleged overpayments. The Medicare attorneys at Fenton Law Group regularly defend healthcare providers in Medicare Part B recovery audits and appeals, including Medicare audits by the administrative contractor (i.e. the carrier), formerly NHIC and, effective September 2, 2009, Palmetto GBA. In addition, Fenton Law Group has significant experience defending audits by the program safeguard contractor, Safeguard, LLC (formerly EDS/Cal-BISC), the RAC auditor, PRG Schultz, and other Medicare contractors. We have successfully assisted clients in all stages of the Medicare appeals process. Cases of note include:

  • In 2006, Fenton Law Group represented a physician who provided intravenous immunoglobulin (IVIG), an infusion therapy sought by patients suffering from autoimmune diseases that caused severe neuropathy. In connection with a national effort by Medicare to cut back on IVIG reimbursement, the contractor contended that the patients failed to meet the Medicare-established criteria for IVIG and demanded repayment in excess of $1.4 million of services that were supposedly not reasonable and necessary. On appeal, at hearing, Fenton Law Group used patient and expert testimony to demonstrate medical necessity, resulting in the overturning of all but $300 (two-tenths of one percent) of the total alleged overpayment.
  • In 2007, Fenton Law Group represented a medical group whose multiple offices were alleged to have been overpaid collectively in excess of $5.6 million for diagnostic testing, office visits, and other services that the contractor (NHIC) contended were unwarranted and unnecessary. Fenton Law Group appealed to the Office of Medicare Hearing Appeals (OMHA) and presented testimony from the provider, patients, and experts to refute the audit findings. Following two days of hearings, the administrative law judge issued a decision reducing the overpayment from $5.6 million to $80,000, a reduction of over 98.6%.
  • In 2007, Fenton Law Group defended a physician from whom recovery of over $800,000 was sought based on the abuse of his provider number by a clinic manager whom he failed to supervise adequately. Although Medicare ordinarily holds providers responsible for fraudulent or abusive billing that occurs as a result of insufficient oversight, Fenton Law Group persuaded Medicare to abandon its overpayment demand entirely against the provider based on his forthright disclosure of the fraud and abuse. The provider was excused from any liability.
  • In 2008, Fenton Law Group appealed a Medicare audit that, as a result of inattention by either prior counsel or the Medicare contractor, had been “lost” in the system, depriving the provider of the opportunity to contest overpayment findings. Fenton Law Group sued the contractor and CMS (over the protestations of federal prosecutors) in order to compel the reinstatement of the appeal. Following the reinstatement, Fenton Law Group defended the provider before OMHA, where the administrative law judge overruled 100% of the overpayment.

While these success stories are no guarantee of results in any particular case, they are reflective of the thorough and tireless approach that Fenton Law Group Medicare attorneys use to defend physicians accused of overpayment by the Medicare Program. These examples highlight why Fenton Law Group is regarded as a premier Los Angeles Medicare law firm, at the forefront of health insurance in California, and leaders in defending Medicare providers in California. In addition to defending recovery audits, Fenton Law Group attorneys also advise providers in navigating complex Medicare and Medi-Cal issues and in Medicare compliance, including Medicare enrollment issues and Medicare Secondary Payor (MSP) issues. Fenton Law Group has also successfully defended providers from claims by private health plans and private payor auditors (such as the Rawlings Group) who attempt to force providers to refund reimbursement based on patient Medicare coverage.

Attorneys Practicing in
Medicare/Medi-Cal Audits, Appeals and Overpayment Disputes

Related Practice Areas